Skin Cancer and Melanoma

Transcript: Skin Cancer and Melanoma Chat
May 5, 2003, 2:00 – 3:00 PM ET

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net chat on skin cancer and melanoma, a live question-and-answer session hosted by Charles Balch, MD. During this hour, Dr. Balch will answer as many questions as time permits. Some questions may be adapted so his answers can help as many people as possible.

Dr. Balch will take questions from 2:00 to 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Balch is unable to give individual medical advice in this setting. In answering questions about specific drugs, Dr. Balch's comments will focus on the state of current research and clinical trials. This chat is governed by all terms and conditions of the People Living With Cancer website.

Good afternoon and welcome. Thank you for joining us. Dr. Balch will now begin taking questions.

Dr. Balch is ASCO's Executive Vice President and CEO and Professor of Surgery and Oncology, Johns Hopkins University School of Medicine. Dr. Balch has led a distinguished career as a clinical and academic surgical oncologist for more than 30 years. He is widely respected as a leading authority in both melanoma and breast cancer and has made significant contributions to laboratory research in tumor immunology. In addition to his work for ASCO and Johns Hopkins, Dr. Balch is Editor-in-Chief of the Annals of Surgical Oncology and Chair of the Scientific Advisory Committee for the U.S. Military Cancer Institute. He is the author of more than 500 published articles and is the editor of Cutaneous Melanoma, regarded as the authoritative textbook on malignant melanoma, now in its fourth edition. Dr. Balch, thank you for taking the time to join us today.

Guest111: How often is skin cancer caused by genetics versus environmental factors like overexposure to the sun?

Dr. Balch: All cancers result from a cancer-causing agent, such as ultraviolet (UV) radiation from the sun or chemicals. That can induce a cancer in a genetically susceptible population. In the case of melanoma, the most susceptible population is fair-skinned people with a tendency to sunburn rather than suntan.

People with deeply pigmented skin, such as African American and Hispanic people, are not at risk for developing melanoma because the pigment protects them from the damage of UV radiation from the sunlight.

Guest139: In your experience, who is most likely to detect a skin cancer, a person doing a self-exam or a physician?

Dr. Balch: In the majority of circumstances, a patient detects a "change" in a mole and brings it to their doctor's attention. The change can include changing color, the surface of the mole, change in size, or an irregular perimeter. In some circumstances, a melanoma can elicit a bothersome "itch" in the area. Patients who have many moles or change in a mole should have regular screening skin exams by a dermatologist or another physician.

ShelluComb: How does a melanoma vaccine work, and where in the United States are they offering it?

Dr. Balch: A promising approach to treating melanoma is the use of melanoma vaccines intended to boost the body's immune responsiveness against melanoma cells and thereby reject or eliminate them. Vaccines come in different preparations that are currently being tested in clinical trials across the nation.

In general, they are being tested in patients after surgery, but who are at high risk for subsequent relapse (e.g. stage III melanoma). I would you suggest you visit the clinical trial section of www.plwc.org if you are looking for specific trials in your geographic area.

Anna: Is a sentinel lymph node biopsy for melanoma considered the standard of care? Also, please describe the procedure.

Dr. Balch: The sentinel node technology is a major advance in the staging of melanoma. It is usually recommended in patients whose primary melanoma is greater than 1.0 mm in thickness. The technique involves mapping the lymph drainage pattern from the skin around the melanoma to the first lymph gland that may be involved with spread or metastasis to the lymph glands. If the sentinel node is removed and does not contain spread or metastasis, then it is highly unlikely that any other lymph glands in the region contain spread or metastasis (with 95% accuracy). On the other hand, if the lymph gland does contain metastasis, then a complete removal of the lymph glands in the region is necessary.

This is simple outpatient procedure and is being applied at most melanoma centers, especially in those circumstances where patients may be eligible for subsequent clinical trials or where the staging information is useful in treatment planning.

shade: What percentage of melanoma is caused by sun exposure?

Dr. Balch: In more than 90% – 95% of melanoma patients, sunlight is thought to cause or significantly contribute to the disease.

dru: What would be the best therapy/treatment regime for a person at stage III metastatic melanoma with only one lymph node involved, all other regional nodes clear?

Dr. Balch: Stage III melanoma involves spread to the regional lymph glands but not beyond, based on clinical and radiologic criteria. High-dose interferon has been approved by the U.S. Food and Drug Administration (FDA) as a treatment approach for stage III melanoma. However, it can have significant side effects and is costly.

At many melanoma centers, other approaches are being explored in prospective clinical trials involving other forms of biological therapy, such as melanoma vaccine preparations.

In general, it is best for stage III melanoma patients to receive some form of biological therapy (immunotherapy), but at present there is no benefit of chemotherapy.

ana: How is skin cancer different from melanoma?

Dr. Balch: Melanoma is one form of skin cancer that affects over 54,000 Americans every year. Compared with other forms of skin cancer, it has the potential for spreading. The more common forms of skin cancer are squamous cell carcinoma and basal cell carcinoma, which can recur locally but rarely spread.

ana: Is melanoma hereditary?

Dr. Balch: Many melanoma patients inherited fair skin from their parents; in addition, there may be other genetic susceptibility factors that are not yet identified. There are some uncommon inheritance patterns, especially those associated with dysplastic nevus syndrome. Individuals with a family history of melanoma should be especially involved in prevention and screening programs as recommended by their doctors.

terri: Is Mohs microscopic surgery the standard for a stage I melanoma and why would someone do a general excision rather than Mohs?

Dr. Balch: In general, the Mohs surgery technique is unnecessary and contra-indicated in the treatment of melanoma, although the Mohs technique is commonly used for other forms of skin cancer, especially basal cell carcinoma. The standard of treatment is to excise a margin of normal-appearing skin around the melanoma, usually one-half to one inch, depending upon the actual tumor thickness. It is unnecessary to take the tumor out using the more elaborate method of Mohs surgery for melanoma.

Nomoresun: I used to tan all summer, but for nearly nine years now I have avoided the sun, worn sunscreen, etc. Have I lessened my chances of getting skin cancer?

Dr. Balch: Definitely yes. However, your previous exposure to sunburning may have caused latent mutations within the moles that could arise years later. Therefore, it is important to examine your skin on a regular basis and see your doctor if there are any irregular, large, or changing moles.

Pboente: What is the role of biochemotherapy in metastatic melanoma?

Dr. Balch: This is a very intensive form of treatment for advanced (stage IV) melanoma that combines high doses of biological therapy and chemotherapy. It is being used at many medical centers but its ability to prolong life has yet to be proven in melanoma clinical trials. Such trials are now being conducted and results should be available in the coming months.

Lakeland: What role does polymerase chain reaction (PCR) play in patients with a diagnosis of melanoma?

Dr. Balch: This is a new molecular marker approach that is been used by pathologists at some centers for detecting microscopic spread of disease. It is still an investigational approach that is not used widely.

BJ: Can basal cell carcinoma turn into melanoma?

Dr. Balch: No. There is no relationship between the two.

Guest349: A friend gave me a topical salve saying it helps remove skin cancers. Can I use this along with the treatments my oncologist is recommending?

Dr. Balch: I have never used this in my practice. There are a large number of "alternative medicine" approaches being advertised, including various forms of nutritional and vitamin therapy. None of these have any proven value in the prevention or treatment of melanoma. They should NEVER be used as a substitute for standard treatments that are used based upon evidence from clinical trials.

One should be wary of unregulated products that may have untoward toxicity and excessive cost without a proven value.

dru: How can I find support groups for long-term metastatic melanoma survivors?

Dr. Balch: There are a number of national patient advocacy groups for melanoma. I would refer you to Cancer.Net's Patient Information Resources area, which will contain links to some of these websites.

Coping: My mother is suffering from grade II lymphedema. What can be done to ease her pain?

Dr. Balch: This is a very difficult problem that can occur after lymph node surgery because alternative lymph circulation does not drain all the tissue fluid in a leg or arm. In general, it can cause discomfort but not pain. I would consult your doctor for recommendations. In my practice, we may use combinations of elastic (compression) stockings, low-grade diuretics, and physical therapy, depending on how disabling the lymphedema is.

Lakeland: What percent of people with melanoma have a desmoplastic type? And does a diagnosis of desmoplastic decrease the five-year overall survival?

Dr. Balch: This is a rare form of melanoma that generally occurs on the face and neck. It is not caused by sunlight. Its biologic behavior is to recur locally because it can invade deeply or along the local nerves for some distance. It oftentimes has to be treated with more radical local surgery along with post-operative radiation. It does not spread as often as locally advanced melanomas.

sunny: Do tanning beds increase your risk of melanoma?

Dr. Balch: This is a controversial area, and there is no proven evidence that it increases the risk of melanoma. However, the use of tanning beds that cause any form of sunburn or prolonged use over months or years could theoretically increase the risk for various forms of skin cancer, including melanoma. We simply don't know the long-term effects of repeated use of tanning beds and the risk of various forms of skin cancer. In general, I don't recommend it.

Guest103: I read an article in the Atlantic Monthly that said people can be more harmed by sunscreen because a false sense of safety makes them get even more sun exposure. Is this true?

Dr. Balch: I have not read the article in the Atlantic Monthly. It is true, however, that use of sunscreen can give a person a false sense of security in the sun. Screens and lotions can dissipate or dilute out with perspiration or bathing, so it is important to regularly reapply them depending upon your circumstance.

Be aware of what your skin is telling you with regard to redness or burning, for everyone's skin has a different ability to shield UV radiation from sunlight. In general, it is not necessary to use SPF (sun protection factor)-rated sunscreen more than SPF 15 to 20. For those who are out in bright sun for prolonged periods, it may be necessary to supplement this with a higher SPF-rated lotion on their lips, nose, or forehead.

Guest268: My 17-year-old niece has been told she has pre-cancerous skin lesions. What exactly does this mean? I thought only older people (who spent years in the sun) could get skin cancer.

Dr. Balch: We are clearly able to diagnose precursor moles based on pathological examination after biopsy. There are various pathological terms associated with these that you can discuss with your doctor. In general, we recommend the excision of moles with "severe atypia," "dysplasia," or "melanoma in-situ." Such diagnoses may indicate that a person's skin may be at increased risk for developing a melanoma later in life. Therefore, such individuals should be screened by a dermatologist on a regular basis.

A mole that is changing is always an indication for a biopsy. Those that have a "pattern" of irregularity should be considered for a biopsy, especially larger moles. This is a judgment you and your doctor would make together about whether to perform a biopsy. In general, a biopsy should always be a complete excision of the mole, not a "shave biopsy," which is commonly used to examine for other kinds of skin lesions.

JiminNY: I was diagnosed with melanoma last year, treated by surgery for 0.75mm, wide local excision clear. How often should I be looked at by a dermatologist?

Dr. Balch: This is an early form of melanoma that is highly curable, in general. In my practice, I would still follow such individuals at least yearly, with a complete examination and chest x-ray. Whether or not one should have more frequent skin examinations depends on the rest of their skin, the number of moles on their body, and other factors.

Approximately 7% of melanoma patients will develop a second melanoma during their lifetime, so prevention and screening of melanoma should be a lifelong part of good health.

Bugs: I had stage II acral lentiginous melanoma between my toes, with removal of my foot and interferon as the treatment. I am now unable to get long term insurance. What are the chances of recurrence of that type of skin cancer? Isn't it rare and is it caused by the sun?

Dr. Balch: This is another uncommon form of melanoma that is not caused by sunlight exposure. It generally presents as a pigmented lesion beneath the toenails or fingernails or on the soles of feet or palms of hands. It can occur in any ethnic group, including African Americans, Hispanics, Asians, and Caucasians. Its biological behavior is somewhat more aggressive than the more common forms of melanoma, although it is still curable.

UKGirl: I live in the United Kingdom. The treatment information I have found on the web is from United States websites. Are the approved treatments in the United Kingdom the same as the United States?

Dr. Balch: The regulatory oversight in the United Kingdom is different than in the United States, so approved drugs and biologics will vary from country to country based upon the levels of evidence from clinical trials and the ability of their health system to dispense them.

Charlie: There seems to be lack of consensus in the medical community about treatment approaches to melanoma–why is that?

Dr. Balch: In fact, there is a high degree of consensus on the treatment of melanoma where there is evidence based upon clinical trials. There may be perceived controversy in areas where there is still-evolving technology or new agents, where there are ambiguous results from clinical trials, or when there are local approaches that have not yet been validated in clinical trials. You should ask your physician about the source of evidence that backs up their treatment recommendations. I would strongly encourage all melanoma patients to enter into clinical trials when they are eligible so that we can resolve controversies in treatment approaches or validate new treatments.

Moderator:The chat is now ending. Thank you for your thoughtful questions. We hope this discussion has been valuable, and we regret not being able to answer every question. Dr. Balch, thanks again for lending us your time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) by 12:00 PM ET tomorrow. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net on June 5, 2003, from 2:00 to 3:00 PM ET for a live chat about advances in cancer research presented at ASCO's 2003 Annual Meeting with Frank Haluska, MD, PhD. Dr. Haluska is Director of Melanoma Research at Massachusetts General Hospital and Chair of ASCO's Cancer Communications Committee.

The chat room is now closed. Thanks again for joining us.